Nevada Medicaid Forms Can Now Be Submitted Using the Provider Web Portal
On July 6, 2015, Nevada Medicaid completed updating all of the Nevada Medicaid forms that are available on this website. These forms have been updated to a format that allows them to be completed, downloaded and saved electronically. In addition, an enhancement has been made to allow some forms to be submitted online using the “Upload Files” page on the Provider Web Portal.
Please see Web Announcement 938 for the list of forms that can be uploaded using the “Upload Files” page on the Provider Web Portal, the types of forms that may not be uploaded, and screenshots and instructions for uploading forms. Upload instructions are also available in the new Electronic Verification System (EVS) User Manual Chapter 8.
Prior Authorization Forms
All prior authorization forms are for completion and submission by current Medicaid providers only.
Enrollment forms are for completion and submission only by providers applying for enrollment in the Nevada Medicaid and Nevada Check Up program.
|FA-34||Provider Voluntary Termination Notice|
Sterilization/Abortion forms are for completion and submission by current Medicaid providers only.
|FA-50||Nevada Medicaid Hysterectomy Acknowledgement Form|
|FA-52||Abortion Affidavit (Rape)|
|FA-53||Abortion Affidavit (Incest)|
|FA-54||Abortion Declaration (Rape)|
|FA-55||Abortion Declaration (Incest)|
|FA-57||Certification Statement for Abortion to Save the Life of the Mother|
Pharmacy forms are for completion and submission by current Medicaid providers only.
Appeals forms are for completion and submission by current Medicaid providers only.
|FA-90||Formal Claim Appeal Request|
The following forms are for the use of Nevada Medicaid Hospice providers.
Emergency Dialysis Case Certification Forms
The following forms are for the use of Nevada Medicaid and Nevada Check Up providers to certify that a non-United States citizen has met the medical conditions to be eligible to receive outpatient emergency End Stage Renal Disease (ESRD) services through the Federal Emergency Services (FES) program.
|FA-100||Initial Emergency Dialysis Case Certification|
|FA-101||Monthly Emergency Dialysis Case Certification|
Nevada DHCFP Forms
The following forms are for the use of Nevada Medicaid and Nevada Check Up providers.
|NMO-7073||Functional Assessment Service Plan|
|NMO-7073 Instructions||Functional Assessment Service Plan Instructions|
|NMO-7073 (SP)||Functional Assessment Service Plan (Spanish)|
|NMO-7073 Instructions (SP)||Functional Assessment Service Plan Instructions (Spanish)|
|NMO-3543||Universal Needs Assessment Tool for 1915(i) Services|
|NMO-3430A||Nevada DHCFP Serious Occurrence Report|
|NMO-3430A Instructions||Nevada DHCFP Serious Occurrence Report Instructions|
|SOR||Nevada DHCFP Serious Occurrence Report (Web-based Version)|
|SOR Instructions||Nevada DHCFP Serious Occurrence Report Instructions (Web-based Version)|